Fire Protection Industry Scheme Reference SP205 Part 1

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1 BAFE Scheme: SP205 Version 4(a): July 2015 Fire Protection Industry Scheme Reference SP205 Part 1 Life Safety Fire Risk Assessment BAFE (British Approvals for Fire Equipment) The Fire Service College, London Road, Moreton-in-Marsh, Gloucestershire GL56 0RH Tel: Fax: This is a BAFE Controlled Document. Changes are not permitted without authorisation from the BAFE Technical Schemes Manager.

2 CONTENTS Foreword 1 Introduction... Page 3 2 Objective... Page 4 3 Scope... Page 4 4 Definitions... Page 4 5 Competencies of Fire Risk Assessors... Page 6 6 Fire Risk Assessment... Page 7 7 Validation... Page 9 8 Certificates of Conformity... Page 10 9 Management System... Page Application for Certification Audit... Page Certification Audit... Page Audit Decision... Page Certification of an Organization... Page Conformity Marking... Page Surveillance Audits... Page Change of Details... Page 18 Appendix A Model Certificate of Conformity... Page 20 Appendix B Determination of Competency of Fire Risk Assessors... Page 21 Appendix C Example Process for determining competence of Fire Risk Assessors... Page 23 Appendix D Fire Risk Assessment contents Page 24 Amendment record. Page 26 Notes to all users of this document: Note 1: The copying of this document is not permitted without the express permission of BAFE except as permitted by Copyright law. Note 2: Use of the BAFE Logo in relation to this Scheme is restricted to those organizations certificated to operate SP205 and is subject to the rules that from time to time may be issued by BAFE. BAFE SP205-1: Version 4(a) July 2015 Page 2 of 26

3 FOREWORD This version of the BAFE Scheme document was published in July 2015 for use by Third Party Certification Bodies (TPCBs) and by those organizations involved in the certification process. A Third Party Certification Body (TPCB) will be eligible to operate this BAFE Scheme when: a) The TPCB has received UKAS product certification accreditation to BS EN ISO/IEC with a scope relevant to SP205, and b) The TPCB has concluded a formal agreement with BAFE. An organization will be eligible for formal certification by a TPCB and for BAFE Listing when they have been successfully audited by the TPCB as meeting the requirements of this Scheme. 1 INTRODUCTION 1.1 This BAFE Scheme has been developed for organizations that provide fire risk assessment services for others. This scheme is designed to give assurance to those commissioning fire risk assessments and give confidence in the quality and relevance of the services being provided. It is essential that the fire risk assessor is a competent person, and the fire risk assessor has a duty of care to the organization on which legislation imposes a requirement for the fire risk assessment. However, the ultimate responsibility for the adequacy of the fire risk assessment rests with the duty holder (which is normally a company) or responsible person rather than with the fire risk assessor. 1.2 This Scheme recognises the importance of providing fire risk assessments that comply with an acceptable set of criteria. 1.3 This BAFE Scheme document specifies requirements to be met by Certificated Organizations and also includes guidance notes and commentaries. The guidance notes and commentaries are advisory and are included to assist those persons needing further advice on the application and implementation of the Scheme. 1.4 The Scheme enables TPCBs to certificate organizations for compliance with the Scheme. 1.5 To be relevant to the end user and attractive to the regulators/enforcers, this Scheme should offer a significant benefit. A Certificate of Conformity issued under a scheme in which all parties have confidence provides that benefit. This Scheme requires that Certificated Organizations will certify their fire risk assessments in accordance with this Scheme. 1.6 This Scheme is designed to encompass different scales of organizations and the different relationships that may exist with the client. To this end, the Scheme should accommodate a range that includes but is not limited to: a. The sole trader providing the fire risk assessment service directly to the client; b. The organization providing the fire risk assessment service to the client and directly employing one or more assessors; and c. The organization providing the fire risk assessment service to the client and employing a sole trader or organization to carry out the assessment. From this it can be seen that competence of the organization is as important as the competency of the individual assessor even if the organization and the assessor are one and the same. 1.7 Additional information relating to the operation of this Scheme can be found in BAFE Scheme document SP205 Part 2 Accreditation Requirements and Guidance. BAFE SP205-1: Version 4(a) July 2015 Page 3 of 26

4 2 OBJECTIVE 2.1 This BAFE Scheme has been developed to permit organizations who carry out fire risk assessments to become third party certificated and listed as recognition of their competence to undertake their scope of work. 2.2 The certificates issued by these Certificated Organizations will provide evidence of conformity with this Scheme and give the end users and relevant enforcing authorities (e.g. fire & rescue authorities) confidence that the fire risk assessment has been correctly undertaken. 2.3 This Scheme document details the minimum requirements to be met by an organization applying for third party certification. TPCBs operating this Scheme may have additional requirements that have to be met before they certificate an organization. Details of additional requirements can be obtained from the relevant certification body. 3 SCOPE 3.1 This BAFE Scheme covers the fire risk assessment for life safety only. 3.2 The scope of this Scheme allows for work to be sub-contracted provided that the Certificated Organization and the sub-contractor(s) fully satisfy the requirements of this Scheme. A sub-contractor does not have to be certificated under the Scheme but must, through a formal agreement with the main contractor, comply with the requirements of the Scheme. 3.3 This Scheme is intended for use in the United Kingdom. 4 DEFINITIONS 4.1 audit An examination by the TPCB. 4.2 BAFE British Approvals for Fire Equipment is the body that owns the SP205 Scheme and is responsible for its maintenance. 4.3 BAFE Listed Organization In the context of this BAFE Scheme, a company or body that has been listed by BAFE as competent to undertake Fire Risk Assessments. 4.4 Certification Audit An audit that has the objective of determining the suitability of an organization to become a Certificated Organization. 4.5 Certificate of Conformity The certificate issued on completion of the fire risk assessment indicating that the fire risk assessment conforms to this Scheme and the requirements of the Specification. 4.6 Certificated Organization An organization that has been awarded a certificate by a TPCB indicating that the organization complies with the requirements of this Scheme. 4.7 competence The ability to apply knowledge, understanding and skills in performing to the standards required by this Scheme. Competent persons shall have sufficient knowledge, experience and skills needed to meet the requirements of the tasks related to the Scheme. Competent persons shall have an awareness of their own limitations. 4.8 client The person or organization on whose behalf the fire risk assessment is being carried out. BAFE SP205-1: Version 4(a) July 2015 Page 4 of 26

5 4.9 fire risk assessment An organised and methodical examination of a defined premises; the activities carried on, or planned to be carried on within the premises; and the premises existing fire safety control measures, in order to establish the potential sources of fire and the likelihood that a fire could start and cause harm to persons in/or around the premises fire risk assessor Person who carries out, and documents, a fire risk assessment Internal Audit of Risk Assessor Competence A process by which the certificated organization monitors and maintains the competence of its fire risk assessors internal review The process by which an organization confirms its processes conform to the requirements of this Scheme key personnel Any person employed by a Certificated Organization whose actions may have a direct impact on a fire risk assessment process, and includes but is not limited to fire risk assessors and validators organization The body responsible for providing the fire risk assessment records The means by which a Certificated Organization is able to maintain its information on fire risk assessments being planned, being undertaken or which have already been undertaken. Such records may be kept in a number of different formats, e.g. on paper or electronic media review The process by which a fire risk assessment is examined and evaluated in order to determine its adequacy Specification A document specifying requirements and which usually forms a part of a legally binding contract sub-contractor An organization that, by formal written agreement, undertakes fire risk assessment work on behalf of the Certificated Organization Surveillance Audit An audit of a Certificated Organization with the objective of determining their ongoing adherence to the requirements of this scheme Third Party Certification Body (TPCB) An organization that has been accredited by UKAS as competent to assess an organization's competence to undertake work in accordance with this Scheme and to subsequently undertake periodic surveillance audits of the ongoing competence of the firm once it has been certificated. The TPCB is required to have UKAS accreditation to BS EN ISO/IEC for the scope of this BAFE Scheme and to be licensed by BAFE UKAS The United Kingdom Accreditation Service. BAFE SP205-1: Version 4(a) July 2015 Page 5 of 26

6 4.22 Validator A named person with the competencies of a fire risk assessor and who has the responsibility and delegated authority to validate documented fire risk assessments on behalf of the Certificated Organization. 5 COMPETENCIES OF FIRE RISK ASSESSORS Commentary In order to produce a fire risk assessment that can satisfy the requirements of the law, it is essential that the person(s) carrying out the fire risk assessment and the Validator(s) are competent in their respective roles. It is particularly important that the TPCB is able to confirm the effectiveness of the process by which the Certificated Organization ensures the competence of their fire risk assessors and the Validators of the fire risk assessment. At the time of developing this scheme there were no nationally recognised and accepted qualifications for fire risk assessors. This Scheme therefore requires that Certificated Organizations have systems in place to ensure that the competency of their fire risk assessor(s) knowledge and skill is appropriate to the work being undertaken. The Certificated Organization should identify the competency requirements of their fire risk assessor(s) and be able to demonstrate that it has individually assessed all fire risk assessors against these requirements. A competent fire risk assessor will demonstrate an enthusiasm for the subject and endeavour to make regular advancement in their professional vocation. The fire risk assessor should have obtained specialist training where appropriate, receive ongoing refresher training and engage in suitable continual professional development. The Certificated Organization should be supporting such training and development needs. TPCB Note: The TPCB should confirm that the Certificated Organization has identified the competency requirements of fire risk assessors, the competency requirements of the Validators and that the Certificated Organization carries out suitable assessments of the competency of their fire risk assessors. 5.1 The Certificated Organization shall demonstrate that it employs fire risk assessors who are competent to operate within the framework of national fire safety legislation of the country in question. 5.2 The fire risk assessor shall be competent and shall understand the requirements of the Specification. The responsibility for the effectiveness of the fire risk assessor rests with the Certificated Organization. 5.3 The Validator(s) shall be a named individual(s). 5.4 The Certificated Organization shall establish a person specification for the fire risk assessor that identifies the knowledge and skills required. The person specification shall identify the minimum competency requirements and any additional competency requirements appropriate to the fire risk assessments being undertaken. 5.5 The Certificated Organization shall establish a person specification for the Validator that identifies the knowledge and skills required. The person specification shall identify the minimum competency requirements and any additional competency requirements appropriate to the reviews being undertaken. Each Validator shall be subject to at least one on-site TPCB witnessed fire risk assessment that they have undertaken or are undertaking to determine their competence. Guidance Note for Clause 5.4 and 5.5 The minimum requirements of the person specifications should be based on nationally recognised Competency Criteria for Fire Risk Assessors, such as that specified in Appendix A-I of the Competency Criteria for Fire Risk Assessors, which is produced by the Fire Risk Assessment Competency Council. BAFE SP205-1: Version 4(a) July 2015 Page 6 of 26

7 5.6 The Certificated Organization shall have an established procedure(s) to ensure that their fire risk assessors and Validators are competent and remain competent. These procedures shall be regularly monitored by the Certificated Organization through a robust and documented process of internal audit. This internal audit shall include an on-site audit of risk assessment work carried out by each risk assessor and Validator within a period not exceeding 36 months. TPCB Note: The TPCB should audit the Certificated Organization s competence maintenance procedure(s) to ensure that it is adequate and effective. Guidance Note for Clause For fire risk assessors evidence of competence should include: Experience in the practice of fire safety; and training records; and listing on a nationally recognised register of fire risk assessors or completion of a nationally recognised training course; and evidence of successful application of knowledge such as an NVQ; and documented continual professional development; See appendices B and C for further guidance on determining the competence of fire risk assessors. 2. Where a certificated organization employs only one fire risk assessor, that organization may rely on the on-going TPCB audit, provided under this scheme, to satisfy this requirement. 3. For the avoidance of doubt where a sub-contracting organization is already SP205 certificated they may be deemed to have satisfied the requirements of this clause. 5.7 The fire risk assessor shall have an understanding of the requirements of this Scheme in relation to the certification of the assessments and the subsequent certification of the fire risk assessment. 5.8 For every fire risk assessment carried out on behalf of the Certified Organization, the fire risk assessor shall keep detailed notes and gather evidence during the assessment which may include but not be limited to observations, notes, photographs, copies of documents and information gained from third parties. 5.9 The Certificated Organization shall keep all evidence gathered during the fire risk assessment including observations, notes, photographs, copies of documents and information gained from third parties and ensure that it is maintained in a secure and accessible condition. Guidance Note for Clause 5.9 Section 8 Management System gives further details of the Scheme s requirements for document control and control of records. 6 FIRE RISK ASSESSMENT Commentary Clients are not always clear what a fire risk assessment involves beyond the legal requirement for one. The purpose and scope of the fire risk assessment should be made clear in some form of specification. The Specification should make clear the methodology such as the application of accepted guidance, using codes of practice or using mathematical modelling techniques. The Specification should indicate how the records of the fire risk assessment will be presented. Any change to the Specification should be agreed with the client. This Scheme applies only to fire risk assessments where the purpose of the risk assessment is to assure life safety in compliance with fire safety legislation. However, certification under this Scheme does not preclude a Certificated Organization from carrying out fire risk assessments for other purposes or combining life safety fire risk assessments with fire risk assessments for other purposes. BAFE SP205-1: Version 4(a) July 2015 Page 7 of 26

8 Fire risk assessment may cover one premises, several premises or only part of a premises and, to avoid confusion, the premises and areas covered should be made explicit in the documented fire risk assessment. The documented fire risk assessment should be presented in a format that is clear and readily understandable to anyone who reads it. It should record every significant detail that was found, an assessment of the nature and severity of fire risk, and the actions recommended for removing or mitigating that risk. A simple tick box exercise or checklist, unsupported by explanatory notes, will not be acceptable. It is important that the documented fire risk assessment records the authority and responsibility of those involved in carrying out the risk assessment including the person named under this Scheme as Validator of the completed fire risk assessment. Fire safety legislation in the UK not only requires the duty holder to carry out a fire risk assessment but also to periodically review the risk assessment. Whether the review is carried out by the certificated organization or not, the review process falls outside the scope of this scheme. However, where the review reveals changes that require amendment of the fire risk assessment, the revisions, regardless of the extent of those revisions, should be subject to the same rigor as the original assessment. 6.1 The fire risk assessment shall be undertaken by an organization that is competent to provide fire risk assessments in accordance with the requirements of this Scheme. Guidance Note for Clause 6.1 Under this Scheme, evidence of compliance with the requirements of Clause 6.1 is a current certificate issued by a TPCB and a current listing as a BAFE Listed Organization. 6.2 The Specification shall make explicit the objectives of the fire risk assessment. 6.3 Each fire risk assessment shall be in accordance with one or more agreed Specification(s). Guidance Notes for Clause 6.3 This can be: A recognised publicly available specification The organization s own standard process. The client s process. A process detailed in the specification. 6.4 The Specification shall clearly describe the process for carrying out the Fire Risk Assessment including how the Fire Risk Assessment is to be documented. TPCB Note: Examples of the process shall be assessed to the satisfaction of the TPCB. 6.5 Where a Client does not provide a Specification the Certificated Organization shall propose a Specification prior to accepting the Client s instruction. 6.6 All fire risk assessments shall conform to the agreed Specification and shall be suitable and sufficient for compliance with the relevant legislation. 6.7 The documented FRA issued to the client by the certificated organization shall be comprehensive and compliant with this scheme document see annex D for a definitive list of criteria that the FRA shall encompass. A tick box or check list approach to fire risk assessment shall be supported by adequate commentary to inform interested third parties as to the reasons why the decision was reached as to the adequacy or inadequacy of each relevant provision. Guidance Note for Clause 6.7 A simple tick box exercise would not normally be acceptable 6.8 Where it becomes necessary to change the Specification during the course of the fire risk assessment the change and the reasons for it, shall be documented and agreed in writing with the client. BAFE SP205-1: Version 4(a) July 2015 Page 8 of 26

9 6.9 Where a certificated organization amends, to any degree, a fire risk assessment resulting from a review, the amended fire risk assessment shall be subject to all the requirements of this scheme as if it were a new fire risk assessment. Guidance Note for Clause 6.9 In this context the review is that required by law and should not be confused with any review in the context of management, Audit or Validation. 7 VALIDATION Commentary The validation process has two main objectives; to ensure the report is in a fit state to be send to the customer and, as part of the internal quality assurance process. The internal quality assurance process should, among other things, identify any skills/knowledge gaps of the assessor. It is difficult for the writer of any document to recognize errors in their own work; so ideally the fire risk assessment report should be validated by someone else with at least comparable skills. In larger organizations, employing two or more assessors, a system of peer review should be easy to establish, however, in small organizations there may only be one assessor. Therefore this scheme adopts a two pronged approach. In organizations where there are two or more assessors, with just a few exceptions, each and every report would be validated and that validation would be done by a competent person other than the assessor. In addition a sample of reports would be audited by the CB, ensuring consistency of assessments and reviews, see also 11. CERTIFICATION AUDIT. In organizations where there is only one assessor, the assessor is expected to carry out a separate exercise to objectively review their work as part of the validation process. While, arguably, not a thorough as peer review, this should pick up most errors and omissions. In addition the CB would examine a sample of reports during each audit which should highlight shortfalls in the organisations process and in the assessor s skills and knowledge. The combined effect, though not perfect, should provide sufficient assurance of quality. In all organizations, at least one person would be nominated to validate completed fire risk assessment reports. See 5 COMPETENCIES OF FIRE RISK ASSESSORS This scheme recognises that in certain inherently low risk promises the degree of rigor referred to above may not be necessary. This is particularly true where the; design and use of premises are almost identical, the same organization is responsible for running all the premises and the assessments are carried out by the same assessor. The assessor would have the advantage of being able to compare and contrast the premises making anomalies on a single premises and systemic anomalies more obvious. Clearly the reports would be almost identical and nothing would be gained by validating every report. 7.1 Each and every fire risk assessment shall be validated and verified by a Validator. Guidance Note for Clause 7.1 In an organization where only one person carries out fire risk assessments, the Fire Risk Assessor will also be the Validator. This person must meet the competency requirements for Validators and be able to demonstrate through records, that validation is carried out objectively and is a separate activity to the Fire Risk assessment. 7.2 For the validation process to take place, the fire risk assessment shall satisfy the requirements of the specification and the requirements of this Scheme. 7.3 Fire risk assessments shall only be signed-off by a Validator of the Certificated Organization. 7.4 Where FRAs are carried out under a single contract: It is permissible for the FRAs to be subject to sample review and signed off as a batch by a Validator subject to the following criteria: BAFE SP205-1: Version 4(a) July 2015 Page 9 of 26

10 i. For retail/commercial premises comprising no more than two occupied floors (ground and first), single occupancy, no more than 10 occupants and does not comprise any form of sleeping risk ii. Low rise, low risk (four storeys or fewer) housing premises of a specific generic type Irrespective of (i) or (ii) above, if the FRA indicates that the premises in question is of medium or high risk then that FRA shall be subject to validation The sample size should be a minimum of two or 10%, whichever is the greater, per assessor used on the contract The certificated organization shall keep a register identifying which FRAs have been reviewed as part of the sampling process and which fire risk assessor carried out the FRAs that have been reviewed. The identity of the Validator(s) carrying out the review shall also be recorded on the register. 8 CERTIFICATES OF CONFORMITY Commentary To comply with this Scheme the Certificated Organization should provide fire risk assessments of consistently good quality. For the fire risk assessment to be of value to the client and other interested parties they must have confidence in the fire risk assessment and the organization that provided it. The Certificate of Conformity is a clear statement that the Certificated Organization produced the fire risk assessment for life safety, it is suitable and sufficient and compliant with this Scheme and is certified by a traceable competent individual. 8.1 Prior to the Certificate of Conformity being completed, the fire risk assessment shall have been validated and verified. 8.2 A Certificated Organization shall issue a Certificate of Conformity for every fire risk assessment that it carries out that wholly or partly addresses life safety. 8.3 A Certificated Organization shall not issue a Certificate of Conformity for any fire risk assessment that does not address life safety. 8.4 Where life safety and other aspects of fire protection are addressed in the same fire risk assessment a Certificate of Conformity shall be issued but the certificate shall make clear that the certificate applies only to the life safety aspects of the fire risk assessment. 8.5 A Certificated Organization shall not issue a Certificate of Conformity for any fire risk assessment that it has not carried out. 8.6 Where a single fire risk assessment covers more than one building or more than one premises a single Certificate of Conformity shall be issued provided that it could be demonstrated that the fire risk assessment forms a single coherent documented exercise. 8.7 Where a Certificate of Conformity covers more than one building or more than one premises the reasons should be fully justified and documented. 8.8 The Certificate of Conformity shall include: a. The BAFE Logo as supplied by BAFE, b. The TPCB Logo as supplied by the TPCB, c. TPCB's certificate designation information as supplied by the TPCB, d. A statement of conformity to this Scheme, e. Name of issuing Certificated Organization, f. BAFE registration number of issuing Certificated Organization, BAFE SP205-1: Version 4(a) July 2015 Page 10 of 26

11 g. The name of client and details of the location for which the fire risk assessment was provided. Where this is only part of the premises or multiple premises, this shall be made clear, h. Specification to which the fire risk assessment conforms, Note: Typically this would be the Certificated Organization s own specification, the client s specification or it may be a third party specification such as PAS79. i. Brief description of the scope and purpose of the fire risk assessment, j. Effective date of the fire risk assessment, k. Recommended date for periodic review of the fire risk assessment, l. A unique identifier for the certificate, m. Date of issue of the certificate, n. The signature and job title of the Validator, o. Name and address of the Third Party Certification Body, and p. A statement that the certificate and the Scheme only relates to life safety fire risk assessment. Guidance Note for Clause 8.8 See appendix A for model certificate 9 MANAGEMENT SYSTEM Commentary For an organization to consistently provide fire risk assessments of a high standard the organization should be effectively managed. To enable TPCBs to assess the effectiveness of the Certificated Organization s management, the management system needs to be transparent. The management system should include periodic internal reviews of the organization s performance and opportunities for improvement. The management system should include robust processes; for correcting faults or failures (corrective action), for identifying areas of weakness and preventing future faults or failures (preventive action). This Scheme assumes that normally the fire risk assessor is either a direct employee of the Certificated Organization or is a sole trader comprising the Certificated Organization. However, it also recognises that the fire risk assessor may not be a full time employee but may be employed on a part time, temporary, or sub-contracted basis. 9.1 Certificated Organizations operating this Scheme shall operate an effective management system. Guidance Notes for Clause Third party certification to BS EN ISO 9001 by a UKAS accredited certification body with fire risk assessment in their accredited scope may be deemed by a TPCB to constitute significant supporting evidence of compliance with this clause. 2. Certification to BS EN ISO 9001 is not a mandatory requirement for this Scheme. 9.2 As a minimum, the management system shall include the following: Documented procedures including internal audit systems for: Establishing the competence of fire risk assessors, when first appointed and ensuring that their competence is reviewed in a period not exceeding 36 months; Establishing the competence of sub-contractors, where used, when first appointed and ensuring that their competence is reviewed in a period not exceeding 36 months; BAFE SP205-1: Version 4(a) July 2015 Page 11 of 26

12 Guidance Note for Clause For the avoidance of doubt a sub-contractor does not have to be registered with the Scheme but must, through a formal agreement with the main contractor, comply with the requirements of the Scheme. However, where a sub-contractor organization is itself registered under this scheme that may be taken to demonstrate competency Dealing with complaints; Ensuring the satisfactory initiation, execution, supervision and completion of the processes relevant to the Scheme and appropriate to the scale and complexity of the works undertaken; Ensuring that all key personnel have access to, and have knowledge of, relevant up to date data, Codes and Standards; Providing for internal review and amendment of the management system, if appropriate, to ensure its continuing effectiveness and that the Certificated Organization continues to meet the client s expectations, and Enabling the creation, maintenance and disposal of essential documents and records; and where documents and records are held electronically ensuring that there are adequate back up arrangements Records of the complete process for each fire risk assessment which shall be made available, on request, to any interested party, legally entitled to them e.g. TPCBs, fire and rescue service and insurers, and shall: include all observations, notes, photographs, copies of documents and information gained from third parties, in either paper or electronic form, made or collected by the fire risk assessor at the time of the fire risk assessment, and be maintained and made readily accessible for a period not less than five years from the date of completion of the fire risk assessment. Guidance Notes for Clause Records should be available for inspection by the TPCB for each Fire Risk Assessment undertaken. 2. The TPCB should choose samples at random and inspect them as part of its audit of Competence. There should be clear evidence that the Fire Risk Assessments satisfy the Specification requirements Preventive and corrective actions where process problems have been identified. Guidance Note for Clause Corrective and preventive action (CAPA) processes are embedded within BS EN ISO 9001 Quality management system standards, thus BS EN ISO 9001 certification should, for the purposes of SP205, be deemed to satisfy the CAPA requirements of this Scheme. For those Organizations who are not formally BS EN ISO 9001 compliant the TPCB should seek evidence of a CAPA process that follows a 7 step sequence as follows:- 1. Identification clearly define the problem 2. Evaluation appraise the magnitude and impact 3. Investigation make a plan to research the problem 4. Analysis perform a thorough assessment 5. Action plan create a list of required tasks 6. Implementation execute the action plan 7. Follow up verify and assess the effectiveness BAFE SP205-1: Version 4(a) July 2015 Page 12 of 26

13 This process may be evidenced by the existence of the following processes within the Organization:- Errors and failures reporting process Management service quality audits Documentation checks Currency of reference codes Client complaints procedure Client feed-back surveys Third party review Staff / agent training / CPD records Periodic [annual] product / service delivery review Effective internal communications procedure Policy for peer support and specialist intervention Spot checks on service quality Approved sub-contractors and records of periodic review. Guidance Notes for Clause A simple register would suffice. 2. See also Guidance Note for Clause above The management structure of the Certificated Organization. Guidance Note for Clause This could take the form of an organization diagram The responsibilities of key personnel Where appropriate, a register of all instruments and equipment used for measurement, inspection and testing purposes and up to date records of calibration A register of essential documents showing their issue status. This shall include this Scheme document, relevant Standards, Codes of practice and relevant publications Competence records for all key personnel. Guidance Note for Clause The Guidance Note for Clause 5.6 lists evidence of Competence of the Fire Risk Assessor Management reviews, indicating that the management system is regularly reviewed and amended, if appropriate, to ensure the continuing effectiveness by the Certificated Organization and that it continues to meet the client s expectations. 9.3 The Certificated Organization shall have appropriate insurance to cover: a. all statutory requirements and the requirements of the contracts they are engaged in, and b. professional indemnity and public liability. 9.4 The Certificated Organization shall clearly demonstrate that it exercises effective control over the fire risk assessor regardless of the fire risk assessor s contractual relationship with the Certificated Organization. Note 1: To ensure ongoing competence and quality of work, such control shall be equivalent to that applicable to a direct employee. Note 2: Where there is any doubt about the employment status of the fire risk assessor or where the fire risk assessor is clearly employed by a separate and coherent organization (including selfemployed fire risk assessors) that fire risk assessor or organization shall be regarded as a subcontractor and shall comply with the requirements of this Scheme. BAFE SP205-1: Version 4(a) July 2015 Page 13 of 26

14 Guidance Notes for Clause Effective control should include ensuring the fire risk assessor meets the Certificated Organization s minimum competency requirements, follows the Certificated Organization s procedures and is subject to regular reviews. 2. For the avoidance of doubt, franchisees should be considered to be individual organizations. For the purpose of this scheme they will be considered as sub-contractors or organizations requiring certification. 9.5 The Validator shall be under the effective control of the Certificated Organization. 10 APPLICATION FOR CERTIFICATION AUDIT An organization wishing to be assessed to the requirements of this BAFE Scheme shall make a written application to a TPCB A separate application shall be made for each operational location involved in certificating work. While each operational location shall be separately audited, certification can be at the organization s corporate level or at operational location level at the discretion of the TPCB Certification at the organization s corporate level is only permitted when all operational locations where fire risk assessments are undertaken are assessed as satisfactory by the TPCB Organization corporate level certification will be withdrawn if any of the operational locations subsequently withdraws from the Scheme but continues to undertake fire risk assessments. Guidance Note for Clauses 10.2, 10.3 and 10.4 This requirement is necessary to prevent any confusion arising regarding the organization locations from which certificated Fire risk assessments can be obtained The applicant organization shall demonstrate to the TPCB that they have the appropriate competence to undertake fire risk assessments for which they are applying. An organization that is currently trading shall, as part of their demonstration of competence, make available for inspection sufficient fire risk assessments, completed and in progress, representative of the work to which the application relates The TPCB shall have successfully audited sample fire risk assessments carried out by the applicant organization s fire risk assessors prior to granting certification An applicant organization shall permit representatives of the TPCB to have access to the organization s contracting offices in order to examine and audit equipment, documentation and business processes The extent of the audit shall be prescribed by the TPCB having regard to the range, scale and geographical spread and complexity of fire risk assessments undertaken by the applicant Organization. 11. CERTIFICATION AUDIT 11.1 For the purposes of Certification Audit the Certificated Organization s operational location(s) shall be those recorded by the Organization at the time of application for certification under this Scheme. Note See Clause The organization shall have available at all their operational locations(s) the following items for audit by the TPCB's representatives: a. system standards, relevant legislation, b. test instrumentation (when relevant) including records of assessment of accuracy, BAFE SP205-1: Version 4(a) July 2015 Page 14 of 26

15 c. tools (when relevant) together with their operational handbooks etc. Note: this would include computational tools (hardware and software) used for mathematical modelling but excludes business tools, d. a list of fire risk assessments in progress and those completed during the previous 12 months, e. specifications, drawings, records, certificates and reports relating to work in progress and that completed over the previous 12 months, f. any other items that are relevant to the process and that the TPCB reasonably requires, g. evidence that adequate insurance cover is held for the work undertaken, and h. a list of any complaints received on the standard and performance of work relating to fire risk assessments together with details of the actions taken to resolve the complaints Participating organizations shall demonstrate to TPCB auditors that, overall, they have in place suitable policies, procedures, audits, etc. to ensure that personnel are competent for the work they undertake. Guidance Note for Clause 11.3 Training records, audit reports, CVs, and personnel files, are examples of records that may be taken into account by a TPCB when auditing an organization The Certificated Organization s operational location(s) shall be adequate for the business being undertaken The Certificated Organization s operational locations(s) shall provide for the safe storage of important documentation and other data that is necessary for the protection of business continuity. Note: Examples include, but are not limited to, the storage of copies of documents at an alternative, safe, location and the backing up of electronic data to an IT facility at a remote and secure location. Guidance Notes for Clause The Certificated Organization s operational locations(s) i.e. the offices, places of work etc. of an organization certificated to the requirements of SP205 should, ideally, be separate from other commercial premises that are not under the control of the Certificated Organization. The operational locations(s) should also, ideally, be physically separated from domestic premises. 2. It is recognised that in certain circumstances, e.g. when organizations are small, the ideal requirements for a work place may not be fully satisfied. In these circumstances, minimum requirements are likely to be as stated in Clauses , and In special circumstances e.g. where organizations are small, the minimum requirements for premises, specified in sub clauses , and shall apply The area(s) used as a workplace shall be segregated from those used for other purposes. Guidance Note for Clause The workplace should not be an inappropriate area e.g. the kitchen or living room but it may be a spare bedroom that is not used for anything other than the organization s business The area(s) used as a workplace shall be securely lockable in order that important documentation e.g. records of fire risk assessments, quotations, clients' drawings, are not vulnerable to abuse when the area(s) is not occupied by a representative of the organization The area(s) used as a workplace shall be adequately protected to prevent loss of or damage to materials relevant to this Scheme. BAFE SP205-1: Version 4(a) July 2015 Page 15 of 26

16 11.7 The organization shall be fully prepared for the audit by the TPCB's representatives and shall have available all the necessary materials and personnel relevant to the audit process The organization shall provide facilities and shall arrange access for the audit and provide transport to premises where work is selected for audit by the TPCB The certification audit shall include an audit of office administrative systems, and for each Validator, a desk-top audit of two FRAs completed within the preceding 12 month period. Guidance Note for Clause The on-site audit may comprise a witnessed assessment carried out during the course of a fire risk assessment by a fire risk assessor of the Certificated Organization. Alternatively, the on-site audit may involve a visit to premises for which a fire risk assessment was recently carried out by the Certificated Organization. 2. The purpose of the on-site audit is to verify the fire risk assessment processes and procedures that the fire risk assessment is valid and validate the competency procedures. 3. This initial certification audit will include the work of all Validators Where applicable, the TPCB shall nominate a representative sample of the Organizations fire risk assessors [other than Validators] and carry out a desk-top audit of two FRAs completed by each nominated assessor within the preceding 12 month period. The size of the sample should be no less than N rounded to the nearest integer, where N is the total number of fire risk assessors, who are not Validators, employed by or contracted to the Organization. This sample should be representative of all operational locations and areas. Of those persons who are not Validators, at least one shall be selected for an on-site audit. If the result of the TPCB s audits do not confirm the results of the organizations internal audit, further TPCB sampling may be required For each premises visited the TPCB shall audit evidence of the relevant fire risk assessor s practical skills in inspecting premises, identifying fire hazards and shortcomings in fire protection measures or management strategy and in formulating a suitable action plan. 12. AUDIT DECISION On completion of the Certification Audit by the representatives of the TPCB, the organization shall receive an audit report recording any non-compliance and shall agree the time scale for the completion of remedial action The organization shall subsequently be advised by the TPCB of its decision as to whether or not certification is to be granted Where there is a dispute between the organization and the TPCB relating to certification, the organization has the right to invoke the TPCB's appeals procedure established under the requirements of BS EN ISO/IEC CERTIFICATION OF AN ORGANIZATON An organization shall not advertise its services as a Certificated Organization complying with the requirements of this BAFE Scheme or make reference to the work for which it may be certificated until it has been successfully assessed by the Third Party Certification Body (TPCB) as complying with the requirements of this Scheme, is in possession of a current TPCB certificate and is listed by BAFE as a BAFE Listed Organization The TPCB certificate shall remain the property of the TPCB and shall be returned upon request, on cessation of certification for whatever reason. BAFE SP205-1: Version 4(a) July 2015 Page 16 of 26

17 Note: The TPCB expectation will be that the Certificated Organization shall operate within the limits of its competence The Certificated Organization shall, at all reasonable times, make available its TPCB certificate to a representative of the Third Party Certification Body On being granted a TPCB certificate, the Certificated Organization shall undertake to continue to comply with the requirements of this Scheme for the period covered by the certificate A Certificated Organization shall be eligible to remain certificated provided the organization continues to be engaged in fire risk assessment and continues to comply with the requirements of this Scheme and those of the TPCB. 14. CONFORMITY MARKING 14.1 Claiming conformity to this BAFE Scheme document shall be indicated by the following information: a) the number and date of this BAFE Scheme document e.g. SP205, b) the name or trade mark of the Certificated Organization, c) the postal address of the Certificated Organization, and d) where authorized, the relevant TPCB Logo in association with the BAFE Scheme SP205 Logo. Guidance Note for Clause 14.1 Conditions and restrictions for use of the BAFE Scheme SP205 Logo will be notified to the Certificated Organization upon successful completion of certification The Certificated Organization shall not use the BAFE Logo or make any statement with reference to BAFE that, in the opinion of BAFE, is misleading or could bring BAFE into disrepute; to do so can result in cancellation of the Certificated Organization s listing as a BAFE Listed Organization. 15. SURVEILLANCE AUDITS Continued certification is conditional upon the results of Surveillance Audits which are undertaken by the TPCB to verify that the standard of work carried out by the Certificated Organization continues to meet the requirements of this Scheme, and that any non-compliances are satisfactorily cleared within the agreed time period. Guidance Notes for Clause The Surveillance Audit should include sufficient fire risk assessments to permit the TPCB to audit the range of work covered by the organization. 2. The Surveillance Audit should include sufficient completed fire risk assessments to demonstrate competence in all aspects covered by the scope of certification. 3. The duration of the Surveillance Audit should be sufficient to audit the fire risk assessment work covered by the Organization s scope of certification and all the management system documentation and records covered within Clause 8 Management Systems. 4. Fire risk assessors should be audited on a rolling programme The frequency and duration of Surveillance Audits will be determined by the TPCB and will depend upon the individual organization s situation and circumstances The first surveillance Audit shall take place at each certificated location not more than six months after the certification audit. The second and subsequent surveillance audits shall take place at intervals determined by the TPCB and at intervals no greater than twelve months. BAFE SP205-1: Version 4(a) July 2015 Page 17 of 26

18 Guidance Notes for Clause Surveillance Audits may have to be split into several shorter visits where the fire risk assessment work covered by the organization s scope of certification is not all available at the time of the planned Surveillance Audit. 2. It is recognised that the stated objectives for Surveillance Audits can be effectively achieved by means of sampling techniques providing the TPCB effectively manages the sampling frequency. 3. Based on the findings of the audit the TPCB may require the period before the next Surveillance Audit to be reduced The TPCB shall nominate a different representative sample of the organisations fire risk assessors, other than Validators, and carry out a desk-top audit of two FRAs completed by each selected assessor within the preceding 12 month period. The sample for each successive surveillance audit should, where practicable, nominate fire risk assessors who have not previously been audited. In nominating these samples, priority should be given to including those fire risk assessors who do not demonstrate the evidence of competency recognised in SP205-1 guidance note to The size of the sample should be no less than 0.6 N rounded to the nearest integer, where N is the total number of fire risk assessors, who are not Validators, employed by or contracted to the Organization. This sample should be representative of all operational locations and areas. Of those persons who are not Validators, at least one shall be selected for an on-site audit. If the result of the TPCBs audits do not confirm the results of the organizations internal audit further TPCB sampling may be required Where the certificated organization has given notice to the TPCB that it has nominated a new Validator, and where, in the opinion of the certificated organization that nominated person is critical to the organizations work throughput, the TPCB shall carry out a dedicated audit of the nominee s competence Where, during a Surveillance Audit, the TPCB discovers adverse trends, a special audit shall be carried out by the TPCB normally within 30 days from the date of the routine Surveillance Audit, to verify that satisfactory corrective and preventive action has been taken by the organization to ensure that the standard of work carried out meets the Scheme requirements Where, during a Surveillance Audit, the TPCB finds that the overall standard of work falls below the Scheme requirements or where the organization has not satisfactorily cleared any noncompliance by the agreed date, the organization s certification shall be suspended for a period of time decided by the TPCB By the end of such period of suspension the organization shall demonstrate that adequate action has been taken to improve the standard of work to an acceptable level or has cleared the outstanding non-compliances. Where the organization fails to achieve this, the certification shall be withdrawn Where an organization having had its certification withdrawn wishes to re-join the Scheme it shall submit a new application and undergo a complete re-certification Audit. 16. CHANGE OF DETAILS A Certificated Organization shall give the TPCB notice in writing of any proposed changes to its legal constitution or other changes, which may affect its certification A change of personnel, where their competence formed part of the certification audit, or where, in particular, a new Validator is nominated, the TPCB shall be notified in writing within 30 days of it taking place and recorded in a register of competent personnel and the register shall be included as a recognised part of the organization s management system Where changes within the organization are such that in the opinion of the TPCB the conditions under which certification was granted are significantly affected, the Certificated Organization shall make a new application for certification. BAFE SP205-1: Version 4(a) July 2015 Page 18 of 26

19 16.4. The Certificated Organization shall accept that at any time the TPCB has the authority to grant, maintain and, subject to appeal, cancel the certification Upon cancellation of certification, however determined, the organization shall immediately discontinue use of all advertising matter, stationery, etc. containing reference to certification and return any certification documents as required by the TPCB. BAFE SP205-1: Version 4(a) July 2015 Page 19 of 26

20 Appendix A Model Certificate of Conformity - (Informative) TPCB LOGO TPCB's Certificate Designation Information SP205-1 Life Safety Fire Risk Assessment Certificate of Conformity This certificate is issued by the organization named in Part 1 of the schedule in respect of the fire risk assessment provided for the person(s) or organization named in Part 2 of the schedule at the premises and / or part of the premises identified in Part 3 of the schedule. Schedule Part 1a Part 1b Part 2 Part 3a Part 3b Part 4 Part 5 Part 6 Part 7 Name of issuing Certificated Organization BAFE registration number of issuing Certificated Organization Name of client Address of premises for which the fire risk assessment was carried out Part or parts of the premises to which the fire risk assessment applies Brief description of the scope and purpose of the fire risk assessment Effective date of the fire risk assessment Recommended date for review of the fire risk assessment Unique reference number of this certificate We, being currently a 'Certificated Organization' in respect of fire risk assessment identified in the above schedule, certify that the fire risk assessment referred to in the above schedule complies with the Specification identified in the above schedule and with all other requirements as currently laid down within the BAFE SP205 Scheme in respect of such fire risk assessment. Signed for and on behalf of the issuing Certificated Organization Name and job title Date of issue (DD/MM/YYYY) Name and address of XXXX Third Party Certification Body BAFE, The Fire Service College, London Road, Moreton-in-Marsh, Gloucestershire, GL56 0RH BAFE SP205-1: Version 4(a) July 2015 Page 20 of 26

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